DEPRESCRIBING OF BENEFIT TO OLDER PATIENTS, BUT IT TAKES CARE

EMBARGOED UNTIL 12.01am, Monday, 22 September 2014

WEANING older patients off inappropriate medications which may harm them more than help
them should be a priority for all prescribing clinicians, say the authors of two clinical focus articles
published in the Medical Journal of Australia.
Deprescribing the process of reducing or stopping drugs, with the goal of minimising
polypharmacy and improving outcomes has the potential to relieve unnecessary medication-
related adverse events and disability in vulnerable older people, the authors wrote.
Associate Professor Ian Scott, from the Department of Internal Medicine and Clinical Epidemiology
at Princess Alexandra Hospital in Brisbane, and colleagues wrote that one in five prescriptions
issued to older adults were inappropriate.
One in four community-living older people are hospitalised for medication-related problems over a
5-year period and 15% of older patients attending general practice report an adverse drug event
(ADE) over the previous 6 months, the authors wrote.
At least a quarter of these ADEs are potentially preventable.
Up to 30% of hospital admissions for patients over 75 years of age are medication-related, and up
to three-quarters are potentially preventable.
Research had shown that the single strongest predictor of inappropriate prescribing and increased
risk of ADEs was the number of medications a person was taking, the authors said.
People in residential aged care facilities are prescribed, on average, seven drugs.
Barriers to deprescribing include an underappreciation of the extent of polypharmacy-related
harms; increasing intensity of medical care and drug therapy; a too-narrow focus on inappropriate
use of drugs whose benefits are mostly outweighed by harm but account for relatively few ADEs,
while ignoring the fact that commonly prescribed drugs with proven benefits in many older people
. . . are more frequently implicated; and resistance of prescribers to discontinue medication,
particularly that prescribed by specialists.
Patients were also often reluctant to cease medications that may have helped them stay alive and
symptom free.
The second MJA clinical focus article, by Dr Emily Reeve and her coauthors, from the Division of
Health Sciences at the University of South Australia in Adelaide, said that although evidence to
date suggested deprescribing would produce more benefits than risks, more research was
desperately needed.
More evidence is needed regarding negative, non-reversible effects of ceasing use of certain
classes of medication, Dr Reeve wrote.
She cited the example of acetylcholinesterase inhibitors used in Alzheimer disease. Data have
shown that after donepezil was discontinued, some patients cognitive scores dropped below
pretreatment levels and did not return to those levels despite reinitiation of donepezil.
Both articles concluded that most of the risks of deprescribing could be minimised with proper
planning.
Professor Scott said reframing the issue to one of affirmation for highest quality care and shared
decision making rather than abandonment would help overcome patient reluctance and fears.
Strong lines of communication between doctor and patient, targeting patients at highest risk of
ADEs and drugs most likely to be non-beneficial, and consistency of care from one clinician over
an extended period of time were also vital to the success of deprescribing.
Inappropriate polypharmacy and its associated harm is a growing threat among older patients that
requires deliberate yet judicious deprescribing using a systematic approach.

Widespread adoption of this strategy has . . . considerable potential to relieve unnecessary
suffering and disability, as embodied in that basic Hippocratic dictum first do no harm,
Professor Scott concluded.

Please acknowledge the Medical Journal of Australia (MJA) as the source of this article.

The Medical Journal of Australia is a publication of the Australian Medical Association.
The statements or opinions that are expressed in the MJA reflect the views of the authors and do not represent the official policy of the AMA or the
MJA unless that is so stated.

CONTACTS: A/Prof Ian Scott 0412 668 472
Dr David Le Couteur 0407 250 823

Dr Michael Wiese 0408 159 539
Ms Michele Nardelli 08 8302 0966
On behalf of Dr Emily Reeve [this article was written (and based on work
conducted) while Dr Reeve was at the University of South Australia she is
now employed at University of Sydney]